Perinatal management of trisomy 18: a survey of obstetricians in Australia, New Zealand and the UK

OBJECTIVE

The objective of this study was to explore the attitudes of obstetricians in Australia, New Zealand and the UK towards prenatally diagnosed trisomy 18 (T18).

METHOD

Obstetricians were contacted by email and invited to participate in an anonymous electronic survey.

RESULTS

Survey responses were obtained from 1018/3717 (27%) practicing obstetricians/gynaecologists. Most (60%) had managed a case of T18 in the last 2 years. Eighty-five per cent believed that T18 was a 'lethal malformation', although 38% expected at least half of liveborn infants to survive for more than 1 week. Twenty-one per cent indicated that a vegetative existence was the best developmental outcome for surviving children. In a case of antenatally diagnosed T18, 95% of obstetricians would provide a mother with the option of termination. If requested, 99% would provide maternal-focused obstetric care (aimed at maternal wellbeing rather than fetal survival), whereas 80% would provide fetal-oriented obstetric care (to maximise fetal survival). Twenty-eight per cent would never discuss the option of caesarean; 21% would always discuss this option. Management options, attitudes and knowledge of T18 were associated with location, practice type, gender and religion of obstetricians.

CONCLUSION

There is variability in obstetricians' attitudes towards T18, with significant implications for management of affected pregnancies.

The impact of national guidance for anomaly screening and invasive testing: unintended consequences

Recent guidance from the UK National Screening Committee (NSC) and the Fetal Anomaly Screening Programme (FASP) has led to important changes in prenatal ultrasound diagnosis and invasive testing. These relate to prenatal ultrasound investigation of what were previously known as 'soft markers' for Down's syndrome at the time of the detailed anomaly scan and as to whether full karyotype or FISH (fluorescent in situ hybridisation)/QFPCR (quantitative fluorescence PCR) testing for trisomies should be carried out when an invasive test is performed. Neither recommendation is directly related to the other but both in combination could have profound implications for the detection of chromosomal abnormalities other than trisomy 21 (Down's syndrome). In the light of two cases recently managed in one regional fetal medicine unit, we retrospectively reviewed cases where, with correct application of the NSC and FASP recommendations, non-lethal and clinically important chromosomal abnormalities would most likely not have been detected.

Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE)

OBJECTIVES

Few data exist for counseling and perinatal management of women after an antenatal diagnosis of early-onset fetal growth restriction. Yet, the consequences of preterm delivery and its attendant morbidity for both mother and baby are far reaching. The objective of this study was to describe perinatal morbidity and mortality following early-onset fetal growth restriction based on time of antenatal diagnosis and delivery.

METHODS

We report cohort outcomes for a prospective multicenter randomized management study of fetal growth restriction (Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE)) performed in 20 European perinatal centers between 2005 and 2010. Women with a singleton fetus at 26-32 weeks of gestation, with abdominal circumference < 10(th) percentile and umbilical artery Doppler pulsatility index > 95(th) percentile, were recruited. The main outcome measure was a composite of fetal or neonatal death or severe morbidity: survival to discharge with severe brain injury, bronchopulmonary dysplasia, proven neonatal sepsis or necrotizing enterocolitis.

RESULTS

Five-hundred and three of 542 eligible women formed the study group. Mean ± SD gestational age at diagnosis was 29 ± 1.6 weeks and mean ± SD estimated fetal weight was 881 ± 217 g; 12 (2.4%) babies died in utero. Gestational age at delivery was 30.7 ± 2.3 weeks, and birth weight was 1013 ± 321 g. Overall, 81% of deliveries were indicated by fetal condition and 97% were by Cesarean section. Of 491 liveborn babies, outcomes were available for 490 amongst whom there were 27 (5.5%) deaths and 118 (24%) babies suffered severe morbidity. These babies were smaller at birth (867 ± 251 g) and born earlier (29.6 ± 2.0 weeks). Death and severe morbidity were significantly related to gestational age, both at study entry and delivery and also with the presence of maternal hypertensive morbidity. The median time to delivery was 13 days for women without hypertension, 8 days for those with gestational hypertension, 4 days for pre-eclampsia and 3 days for HELLP syndrome.

CONCLUSIONS

Fetal outcome in this study was better than expected from contemporary reports: perinatal death was uncommon (8%) and 70% survived without severe neonatal morbidity. The intervals to delivery, death and severe morbidity were related to the presence and severity of maternal hypertensive conditions.

Pregnancy outcome after elective cervical cerclage in relation to type of suture material used

Cervical weakness is an important cause of late miscarriage and extreme preterm labour. Women have been traditionally offered a cervical cerclage procedure, though studies failed to demonstrate a therapeutic effect. None of these studies has addressed the effect of non-braided to braided suture material on cerclage outcome. Type of suture material is an important determinant of surgical outcomes. This issue is of particular relevance to cerclage because the traditionally braided suture has been associated with increased risk of infection in other surgical procedures. Indeed, infection is an important underlying cause for cerclage failure. It is for this reason that some surgeons use non-braided suture material. Therefore, we hypothesise that the unrealised benefit of cervical cerclage is at least in part due to the type of suture material used. In this article, we present the rationale behind our hypothesis and a proposed way of testing it.

Simple two-dimensional ultrasound technique to assess intrapartum cervical dilatation: a pilot study

OBJECTIVES

To describe a two-dimensional (2D) ultrasound technique to measure cervical dilatation in labor, and to compare ultrasound with digital measurements.

METHODS

2D transperineal ultrasound was performed in 21 nulliparous women in labor with a singleton fetus in cephalic presentation and cervical dilatation measured before or after a digital vaginal examination. The absolute difference was calculated and Bland-Altman analysis was used to assess the mean difference between digital vaginal examination and ultrasound examination of cervical dilatation. Pearson analysis was used to determine the correlation between digital and ultrasound measurements. Intraclass correlation coefficients (ICCs) with 95% CI were used to evaluate the reliability of the two methods.

RESULTS

Satisfactory quality images of the cervix were obtained in 19 of 21 cases. There was positive correlation between 2D ultrasound measurement of cervical dilatation and digital vaginal examination (Pearson coefficient r = 0.821, n = 19, P < 0.001). Bland-Altman analysis showed a mean difference between digital and ultrasound measurements of 0.08 cm (95% limits of agreement: -1.83 to 2.00) and the mean absolute difference was 1.24 cm. The ICC between the two methods was 0.81 (95% CI, 0.58-0.92).

CONCLUSIONS

Assessment and measurement of cervical dilatation by 2D transperineal ultrasound is feasible, with close agreement shown between the technique and digital vaginal examination. The technique that we describe could represent an important component of a 'sonopartogram' for ultrasound assessment of labor progress.

High-intensity focused ultrasound in obstetrics and gynecology: the birth of a new era of noninvasive surgery?

Although ultrasound is an essential investigative modality in obstetrics and gynecology, the potential for therapeutic high-intensity focused ultrasound (HIFU) (also referred to as focused ultrasound surgery, FUS) to offer an alternative to invasive surgery is less well known. The ability of HIFU to create discrete regions of tissue necrosis only in precisely targeted positions by careful placement of the focus, without the need for any surgical intervention, has made HIFU of interest to those seeking noninvasive alternatives to conventional abdominal surgery. This article reviews the current experimental and clinical experience with HIFU in obstetrics and gynecology, and outlines potential future applications in fetal medicine and the challenges faced in their development.

Clinical implications of machine-probe combinations on obstetric ultrasound measurements used in pregnancy dating

OBJECTIVE

To investigate the effect of use of different machine-probe combinations on measurement variability and to assess how this variability impacts on accuracy of pregnancy dating.

METHODS

Sixteen different ultrasound machine-probe combinations were used for lateral measurement of targets spaced 10 and 40 mm apart and axial measurement of targets spaced 10 and 50 mm apart in an ultrasound phantom, and differences between the measured and true values were determined. The mean of the 40-mm lateral measurements was used to estimate gestational age using standard obstetric dating tables for crown-rump length (CRL) and femur length (FL) and the mean of the 50-mm axial measurements was used to estimate gestational age using the obstetric dating tables for biparietal diameter (BPD).

RESULTS

As absolute measurements became larger, differences observed using different machine-probe combinations exceeded those due to intraobserver variability. Maximum dating differences for first-trimester CRL of 2 days (based on a measured CRL range of 39-42 mm), second-trimester BPD of 4 days (based on a measured BPD range of 49-52 mm) and FL of 9 days (based on a measured FL range of 39-42 mm) were observed when measurements were transposed to the equivalent gestational age using standard charts.

CONCLUSION

Differences between measured and true values of biometric measurements reflect both machine-probe and intraobserver variability. Incremental first-trimester CRL growth with time is rapid, but second-trimester FL growth is much less so, leaving this lateral measurement more prone to both observer and machine-probe errors. The only axial growth measurement commonly performed is BPD where the measurement differences were intermediate between those of CRL and FL. The differences that can be ascribed to different equipment combinations are in many cases greater than those expected in clinical practice and are of potential importance in determining how fetal biometry is used for dating pregnancies.

Standardized approach for imaging and measuring Cesarean section scars using ultrasonography

Incomplete healing of the scar is a recognized sequel of Cesarean section (CS) and may be associated with complications in later pregnancies. These complications can include scar pregnancy, a morbidly adherent placenta, scar dehiscence or rupture. To date there is uncertainty relating to the factors that lead to poor scar healing and how to recognize it. In recent years, there has been an increase in studies using ultrasound that describe scars as deficient, or poorly, incompletely or inadequately healed with few data to associate the morphology of the scar with the functional integrity of the lower segment of the uterus. There have been multiple attempts to describe CS scars using ultrasonography. Different terminology, methods and results have been reported, yet there is still no consensus regarding the prevalence, clinical significance or most appropriate method to describe the appearances of these scars. Developing a test that can predict the likelihood of women having problems associated with a CS scar is becoming increasingly important. On the other hand, understanding whether the ultrasound appearances of the scar can tell us anything about its integrity is not well supported by the research evidence. In this article we present an overview of ultrasound-based definitions and methods used to describe CS scars. We also present information relating to the performance of alternative techniques used to evaluate CS scars. Having examined the current evidence we suggest a standardized approach to describe CS scars using ultrasound so that future studies can be meaningfully compared.

Clinical implications of intra- and interobserver reproducibility of transvaginal sonographic measurement of gestational sac and crown-rump length at 6-9 weeks' gestation

OBJECTIVES

To assess intra- and interobserver agreement of routinely performed measurements-crown-rump length (CRL) and mean gestational sac diameter (MSD)-for assessing the likelihood of miscarriage in the first trimester of pregnancy using transvaginal sonography.

METHODS

A cross-sectional study of CRL and gestational sac measurements in first-trimester pregnancies was conducted in a fetal medicine referral center with a predominantly Caucasian population. Gestational age ranged from 6 to 9 weeks. All patients underwent a transvaginal ultrasound examination using a high-resolution ultrasound machine. Two measurements of CRL and measurements of three diameters of the gestational sac were obtained by two observers. Agreement within and between observers for CRL and between observers for MSD was analyzed using 95% prediction intervals, Bland-Altman plots with 95% limits of agreement and the intraclass correlation coefficient (ICC).

RESULTS

In total 54 patients were included in the study, with measurements obtained by both observers in 44 of these. Intra- and interobserver ICCs were high for CRL measurements, with values of 0.992 and 0.993 for intraobserver agreement and 0.993 for interobserver agreement. For the MSD, the interobserver ICC was 0.952. Limits of agreement were ± 8.91 and ± 11.37% for intraobserver agreement of CRL and ± 14.64% for interobserver agreement of CRL. For MSD, the interobserver limits of agreement were ± 18.78%. For an MSD measurement of 20 mm by the first observer, the prediction interval for the second observer was 16.8-24.5 mm. For a CRL measurement of 6 mm, the prediction interval for the second observer was 5.4-6.7 mm.

CONCLUSION

For dating purposes, there is reasonable reproducibility of CRL measurements using transvaginal ultrasonography at 6-9 weeks' gestation. When diagnosing miscarriage based on measurements of CRL care must be taken for values close to any decision boundary. The higher interobserver variability that we observed for MSD has implications for the diagnosis of miscarriage based on this measurement in the absence of a visible embryo or yolk sac.

Umbilical artery pulsatility index and fetal abdominal circumference in isolated gastroschisis

OBJECTIVES

To investigate changes in abdominal circumference (AC) and umbilical artery pulsatility index (UA-PI) with gestation in fetuses with isolated gastroschisis, and to determine whether a relationship exists between UA-PI and fetal AC.

METHODS

Data from 58 pregnancies with isolated gastroschisis diagnosed at between 24 and 36 weeks' gestation were included in the study. Z-scores were calculated with respect to expected UA-PI values in normal pregnancies after log-transformation. AC-Z-scores were calculated with respect to expected size in normal pregnancies according to a standard chart. Functional linear discriminant analysis (FLDA) was applied to generate 50(th), 5(th) and 95(th) percentile curves for changes in both AC and UA-PI with gestational age in fetuses with gastroschisis. These curves were compared with the standard curves, as were the means. UA-PI was also plotted against AC. For this relationship, a robust Spearman correlation coefficient was obtained with FLDA.

RESULTS

In fetuses with gastroschisis, there was a highly significant negative correlation between UA-PI and AC, normalized for gestation using Z-scores (median correlation coefficient, - 0.289; median P = 0.000023). Moreover, compared with standard curves AC was lower and UA-PI higher in the gestational-age range studied. Both the AC and UA-PI curves showed a significantly different rate of change with gestation compared with the normal ranges. The mean values for fetuses with gastroschisis compared with the standard AC and UA-PI range curves were significantly different for AC throughout gestation, and for UA-PI from 32 weeks' gestation.

CONCLUSIONS

In fetal gastroschisis, it is well known that AC tends to be smaller, though UA-PI has not been reported to be abnormal in any consistent way. There is a clear relationship between the fetus's AC for gestation and UA-PI, which is not the case for normally grown fetuses. The data suggest that the growth restriction seen in gastroschisis may be explained by hypoxia, and not simply by the classical explanation of extra-abdominal displacement of the abdominal viscera.

Detection of lip, alveolar ridge and hard palate abnormalities using two-dimensional ultrasound enhanced with the three-dimensional reverse-face view

OBJECTIVE

The aim of this study was to assess conventional two-dimensional (2D) ultrasound enhanced with a three-dimensional (3D) ultrasound technique, the 'reverse-face' view (3D-RF) in prenatal evaluation of the involvement of the lips, alveolar ridge and secondary palate in suspected isolated orofacial clefting.

METHODS

One hundred and twenty-four cases of suspected orofacial clefting diagnosed by a routine 2D ultrasound scan were referred for specialist ultrasound at 20-34 weeks' gestation for a detailed assessment of the lips and palate using both 2D and 3D ultrasound. For the 3D examination the lips and alveolar ridges were examined both in profile and in the frontal plane. The palate was then assessed in the reverse coronal view by rotating the face through 180° on the vertical axis to produce the 3D-RF view. Antenatal diagnoses were compared with postnatal findings. Left and right lip and alveolar ridge defects were counted separately according to the Kernohan 'striped Y' classification.

RESULTS

Of 124 patients, 110 had isolated facial clefts and were available for follow-up; in 10, 3D-RF views were not successfully obtained, leaving 100 cases for assessment. The sensitivity of the 2D enhanced with 3D-RF technique for the diagnosis of cleft of the lip was 116/122 (95%), false-positive rate (FPR) 7.7%; for alveolar ridge was 87/103 (84.5%), FPR 7.2%; and for hard palate was 61/68 (89.7%), FPR 15.6%.

CONCLUSION

The data reported represent the largest series of orofacial abnormalities diagnosed by 2D ultrasound and enhanced with 3D imaging to refine the detection of clefts of the hard palate. The technique is feasible in 90% of patients in whom almost 90% have a correct classification of clefts of the lip, alveolar ridge and palate.

Cord coiling, umbilical cord insertion and placental shape in an unselected cohort delivering at term: relationship with common obstetric outcomes

BACKGROUND

The position of the placental cord insertion, its shape and cord coiling are thought to be associated with perinatal outcome. This study derives indices describing the relationship of cord insertion to the placental centre, the shape of the placenta and cord coiling in placentas from unselected term pregnancies. Further, we investigate these indices in pregnancies affected by pre-eclampsia (PET), pregnancy induced hypertension (PIH), gestational diabetes mellitus (GDM) and delivery of a small for gestational age (SGA) baby.

DESIGN/METHODOLOGY

Eight hundred and sixty one unselected women with singleton pregnancy delivering at 37-42 weeks were prospectively recruited to this study. Placental axes and their relationship with the cord insertion were measured using digital photography and proprietary software. From these, the cord centrality (distance of umbilical cord insertion from the centre) and placental eccentricity (deviation of the placental shape from circular) were derived. The cord coiling index (number of coils in the cord divided by the length of cord in cm) was also calculated from manual measurements.

RESULTS

The mean value of cord centrality index was 0.36 (SD = 0.21) and of placental eccentricity 0.49 (SD = 0.17). Left direction of umbilical cord coiling was more common than right (79% vs 16.4%) The mean cord coiling index was 0.20 (SD = 0.09) coils/cm. The indices were constant between 37 and 42 weeks and were no different in the non-affected population compared to women with pre-eclampsia (n = 17), PIH, (n = 27), GDM (n = 38) or delivery of an SGA baby (n = 54).

CONCLUSION

The cord centrality index that we derive suggests that the cord insertion is most commonly 'off centre', and eccentricity index that the placental shape is elliptical. Therefore, contrary to widely held belief, the cord does not normally insert centrally nor is the placenta normally round in shape. There is a preponderance of left sided coiling. There was no difference for any of the indices between the non-affected pregnancies and pregnancies affected by pre-eclampsia, PIH, GDM and SGA.

New crown-rump length curve based on over 3500 pregnancies

OBJECTIVES

The Robinson and Hadlock crown-rump length (CRL) curves are commonly used to estimate gestational age (GA) based on the CRL of an embryo or fetus. However, the Robinson curve was derived from a small population using transabdominal sonography and the Hadlock curve was generated using early transvaginal ultrasound equipment. The aim of this study was to use transvaginal and transabdominal ultrasound to study a large population of early pregnancies to assess embryonic or fetal size, and so create a new normal CRL curve from 5.5 weeks' gestation. We compared this with the Robinson and Hadlock CRL curves.

METHODS

A retrospective database study of CRL in first-trimester embryos was conducted in a fetal medicine referral center with a predominantly Caucasian population. Linear mixed-effects analysis was performed to determine the relationship between CRL and GA. After internal validation of this curve, the CRL was compared with the expected CRL at a given GA according to both the Robinson and Hadlock models based on the paired t-test. Bland-Altman plots were constructed to compare the CRL measurements obtained in our study population with those predicted according to GA by both the Robinson and Hadlock curves.

RESULTS

In total 3710 normal singleton pregnancies with a known last menstrual period were included in the study, corresponding to 4387 scans. Our data differed significantly from both the Robinson and the Hadlock curves (paired t-test, P < 0.0001). A mixed-effects model for CRL as a function of GA was developed on 70% of the data and internally validated with z-scores on the remaining 30%. The new curve extended from 5.5 to 14 weeks' gestation. Compared to our CRL curve, the Robinson curve gave a 4-day underestimation of GA at 6 weeks with a difference in CRL of 3.7 mm and a 1-day overestimation from 11 to 14 weeks with a difference in CRL of 0.9-1 mm. A comparison between our curve and the Hadlock curve showed a difference in CRL of 2.7 mm at 6 weeks, equivalent to an underestimation of 3 days, and a difference in CRL of 4.8 mm at 14 weeks, equivalent to an overestimation of 2 days. At 9 weeks all three curves were similar.

CONCLUSION

The new CRL curve suggests differences in the range of CRL measurements compared with the Robinson and Hadlock curves. These differences are most significant at the beginning and the end of the first trimester, and may lead to more accurate estimations of GA.

Ultrasound structural fetal anomaly screening: an update

Screening for fetal anomalies by an ultrasound scan was introduced in many maternity units in the UK in the late 1970s and has become routine in most since then although there is little uniformity as to how the scan is performed and when it is offered. Up to 5% of babies are born with a congenital abnormality. In this review article we will focus on what is already known about screening for the commonest and most serious structural fetal anomalies at the 11-14 and 18-23 week scans, and discuss new techniques that promise to improve the accuracy of screening and diagnosis. Chromosomal abnormalities, "soft markers" and biochemical screening are beyond the scope of this review.

WITHDRAWN: Institutional versus at-home long term care for functionally dependent older people

BACKGROUND

An increasing number of functionally dependent older people require care and medical treatment. Increasingly governments are shifting resources into community care expecting both reduction in costs and improvement in the quality of care. However, it is difficult to establish the costs and benefits of institutional and the alternative at-home care.

OBJECTIVES

To assess the effects of institutional versus at-home care for functionally dependent older people on health outcomes, satisfaction (of functionally dependent older people, relatives and health care professionals), quality of care and costs.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (1999), the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966 to 1999), EMBASE (1980 to 1999), Best Evidence (1990 to 1999), Ageline (1982 to 1999), Cinahl (1982 to 1999), EconLit (1969 to 1999), PsycInfo (1887 to 1999), NTIS (1980 to 1999), Scisearch (1980 to 1999), Sigle (1980 to 1999), and reference lists of related systematic reviews and articles. We contacted authors working in the field in an attempt to identify unpublished studies.

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before and after studies and interrupted time series studies where functionally dependent older people were assigned to either institutional or at-home care.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed study quality. No meta analysis was conducted as only one trial was identified.

MAIN RESULTS

One study was included involving 112 people. This evaluated a community care programme (CCP) organising foster care versus nursing home care. No studies were found where functionally dependent older people returned to their own homes. The included trial was small and of poor methodological quality. No significant difference was found between the two groups when comparing functioning (ADL and IADL), mental status, attitudes to perceived health, life satisfaction or mortality.

AUTHORS' CONCLUSIONS

There is insufficient evidence to estimate the likely benefits, harms and costs of institutional or at-home care for functionally dependent older people.